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Obesity: The Current Landscape

James O. Hill, Ph.D. Anschutz Professor Executive Director Anschutz Health and Wellness Center University of Colorado

Obesity Issues 2013

Why are we so fat? Why do we care? What can we do about it?
Role of the environment National Security Issue Role of Industry Kids What should we be talking about

The Obesity Solution

How Fat are We?

Trends in overweight, obesity and extreme obesity, ages 20-74 years



Extremely Obese

Note: Age-adjusted by the direct method to the year 2000 US Bureau of the Census using age groups 20-39, 40-59 and 60-74 years. Pregnant females excluded. Overweight defined as 24,=BMI; obesity defines as BMI>=30; Extreme obesity defines as BMI>=40.

Trends in child and adolescent overweight

Age 6-11

Age 12-19 Age 2-5

Note: Overweight is defined as BMI>=gender and weight-specific 95th percentile from the 2000 CDC Growth Charts. Source: National Health Examination Surveys II (ages 6-11) and III (ages 12-17), National Examination Surveys, I, II, III and 1999-204, NCHS, CDC.

What Causes Obesity?

Name the top 3 causes of obesity

Potential Causes of Obesity

1. agricultural policies 2. air conditioning, 3. air pollution, 4. antibiotic usage at early age 5. arcea nut chewing, 6. assortative mating, 7. being a single mother, 8. birth by C-section, 9. built environment, 10. chemical toxins, 11. child maltreatment, 12. competitive food sales in schools, 13. consumption of pastries and chocolate (in Burkina Faso), 14. decline in occupational physical activity, 15. delayed prenatal care, 16. delayed satiety, 17. depression 18. driving children to school 19. eating away from home 20. economic development 21. endocrine disruptors, 22. entering into a romantic relationship, 23. epigenetic factors, 24. family conflict, 25. first-born in family 26. food addiction 27. food deserts 28. food insecurity, 29. food marketing to children 30. food overproduction 31. Friends 32. genetics, 33. gestational diabetes, 34. global food system,

Potential Causes of Obesity

35. grilled foods 36. gut microbioata, 37. having children, for women, 38. heavy alcohol consumption, 39. home labor saving devices, 40. hunger-response to food cues, 41. international trade policies (globalization) 42. high fructose corn syrup, 43. lack of family meals, 44. lack of nutritional education, 45. lack of self-control, 46. large portion sizes, 47. living in the suburbs, 48. living in crime-prone areas, 49. low levels of physical activity, 50. low socioeconomic status, 51. market economy, 52. marrying in later life
53. maternal employment, 54. maternal obesity, 55. maternal over-nutrition during pregnancy, 56. maternal smoking, 57. meat consumption, 58. menopause, 59. mental disabilities, 60. no or short term breastfeeding, 61. non-parental childcare 62. overeating, 63. participation in Supplemental Nutrition Assistance Program (formerly Food Stamp Program) 64. perception of neighborhood safety, 65. physical disabilities, 66. prenatal maternal exposure to natural disasters, 67. poor emotional coping 68. sleep deficits, 69. skipping breakfast, 70. snacking,

Potential Causes of Obesity

71. Smoking Cessation, 72. stair design 73. stress 74. sugar-sweetened beverages, 75. trans fats, 76. transportation policies, 77. television set in bedrooms 78. television viewing, 79. thyroid dysfunction 80. vending machines, 81. virus 82. weight gain inducing drugs.

Which of these factors have been changed to impact obesity?

How do we begin to study the problem?

The Energy Balance System

Inherited Factors
Efficiency Adaptive thermogenesis Food preferences

Energy Stores

Environmental Factors
Food environment Physical activity environment

Energy Intake

Active Regulation/Integration

Energy Expenditure

What happens to body weight when food intake i decreased?

Body weight increases Body weight does not change Body weight decreases

Decrease Energy Intake

Usual physical activity Metabolic Rate Food Intake

What happens to body weight when physica activity is increased?

Increase Physical Activity Body weight increases Body weight does not change Body weight decreases

Usual physical activity Metabolic Rate Food Intake

Body Weight
Active Regulation


The obesity epidemic arose from EOut gradual weight gain over time

Which is more important food or phsical activity?

Energy Intake (kcal/day)

2000 1900 1800 1700 1600 1500 1400 1300 1200 1100 1000 1971-74 1976-80

Body Wt (lbs)






130 1988-94 1994-2000

Why are we gaining weight? Occupations and Obesity

TS Church, PLoS One 2011;6(5):e19657.

Walking: Old Order Amish vs. Current Population

18000 14000

Steps per Day ~603 kcal/day 5940 ~436 Kcal/day 5276

Amish Men

Amish Women US Men

US Women

Energy Intake

Energy Expenditure

Our biology works best at high

Physical Activity Threshold for Optimal Weight Regulation

Energy Intake Body Weight

Unregulated Zone Regulated Zone

Metabolic Changes with Decreased Physical Activity

Muscles Insulin Sensitivity Nutrient Metabolism Fat Cells Appetite Brain function

Hypothetical Model for the Cause of the Obesity Epidemic of the Late 20th Century
Body Weight

Energy Intak

Total Energy expenditur

Energy Expenditure in Physical Activity





Role of the Environment?

Addressing the Environment

How do we reduce obsity?

The Energy Balance System

Energy Stores

Energy Intake

Active Regulation/Integration

Energy Expenditure

How much behavior change is needed for successful weight loss maintenance?
-10% (10 kg) = 190-200 kcal/day
Energy Gap

-15% (15kg) = 280-300 kcal/day

Energy Gap Example for 100 kg person

Comparison of weight loss diets with different compositions of fat, protein and carbohydrates (n=811)

Sacks FS. et al. NEJM 2009;360(9) 859-873.

Characteristics of Successful Losers National Weight Control Registry

1.Eating a Reduced Calorie-Reduced Fat Diet 2.Engaging in a high level of physical activity 3.Limiting TV Viewing 4.High level of dietary restraint 5.Frequent self-weighing 6.Maintaining dietary consistency 7.Eating breakfast

Energy Gap for Prevention of Weight Gain (<100 kcal/day)

Energy Gap Energy Gap

Body Weight

Energy Gap



Healthy Weight

The birth of small changes

Addressing Obesity




Biology, Behavior & Environment

Physical Reason to push back Activity
Desire to Eat Pref for sweet/fat No Drive to be active
Little need for physical activity in daily living Attractiveness of sedentary Entertainment Car for Transportation

Healthy Environment


Different Value Equation

Decreased Energy Expenditure

Consume More More for less Greater Productivity

Increased Energy Intake

Social Systems

Available Social Environment of Wellness Good tasting Energy dense Inexpensive Large portions

Make better choices

Whats Missing: the Why

20 years


Role for the private sector?

How Academia Works

Ideas basic and clinical research Development of Science-based programs

Programs evaluated in controlled settings

Implement Programs In the population

Goal: Use science to improve peoples lives

Industry Involvement in Implementation

Ideas basic and clinical research Development of Science-based programs

Programs evaluated in controlled settings

Implement Programs In the population

Diabetes Prevention Program (DPP) 2002

Diabetes Prevention Program (DPP)

Ideas May be possible to prevent diabetes in those at risk basic and Lifestyles factors and glycemic control clinical research Development of Small scale testing Science-based programs of impact of lifestyle

Programs evaluated in controlled settings



Implement Programs In the population

Menu Labeling
Ideas Knowing calorie content could reduce intake basic and clinical research Very little clinical research

Development of No real testing Science-based programs Very little evaluation in controlled settings

Programs evaluated in controlled settings

Implement Programs In the population

Policy to force implementation

Colorado Center for Health & Wellness Center

Education Research


Health & Wellness

Addressing a Complex Issue

Develop and Test Potential Solutions
Create new thinking space for creating solutions Implement Science-Based, Scalable Programs and Initiatives

Community Engagement

Private Sector Partnership

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